Crescent Medical Clinic Family Medicine Clinical Summary 1514 Diamond StSpringfieldOR97477US AntoneREscobar Crescent Medical Clinic Family Medicine 2830 Crescent AveEugeneOR97408US Crescent Medical Clinic Family Medicine 2830 Crescent AveEugeneOR97408US 2830 Crescent AveEugeneOR97408US BeckyJHoward NP 2830 Crescent AveEugeneOR97408US ShelbyGurke NCMA 2830 Crescent AveEugeneOR97408US BeckyJHoward NP
Reason for Visit
Reason For Visit Description Start Date
cough/ congestion 2015/07/21
Chief Complaint
Chief Complaint Description Start Date
cough/ congestion 2015/07/21
Instructions No information available.
Plan of Care
Type Date Detail
Appointment 2015/07/21 04:30 PM - 2015/07/21 04:45 PM Becky J Howard NP, 2830 Crescent Ave, Eugene, OR, 97408-7397, +1-541-686-9000
Appointment
Medications
Medication Instructions Start Date Stop Date Generic Name NDC Provider
PREDNISONE 20 MG TABS 2 tabs p.o. daily Take total daily dose every morning w/ food 2015/07/21 PREDNISONE 66267017230 Becky J Howard NP
ASPIRIN 81 MG TABS Take one tablet by mouth once daily as directed 2015/05/01 ASPIRIN 49999035930 Becky J Howard NP
CARVEDILOL 3.125 MG TABS one bid 2014/06/05 CARVEDILOL 35356051360 Becky J Howard NP
IRBESARTAN 150 MG TABS Take 1 tab by mouth once daily. 2014/06/05 IRBESARTAN 68645040470 Becky J Howard NP
B-12 1000 MCG CR-TABS 2 QD, generic okay 2011/01/04 CYANOCOBALAMIN 40985021104 Teresa Thomas
OTHER (N/A), 1 QD, generic okay 2011/03/08 OTHER (N/A), Gordon P Anderson MD
CO Q 10 CAPS 1 QD, generic okay 2011/01/04 COENZYME Q10 CAPS 54458032311 Teresa Thomas
VITAMIN D3 1000 UNIT CAPS 3 tabs QD 2011/12/16 CHOLECALCIFEROL 11917011811 Brenda Leavitt NCMA
PREDNISONE 20 MG TABS PREDNISONE 2 tabs p.o. daily Take total daily dose every morning w/ food PREDNISONE 2830 Crescent AveEugeneOR97408US BeckyJHoward NP Costco Eugene* 2828 Chad DriveEugeneOR97401US ASPIRIN 81 MG TABS ASPIRIN Take one tablet by mouth once daily as directed ASPIRIN 2830 Crescent AveEugeneOR97408US BeckyJHoward NP Costco Eugene* 2828 Chad DriveEugeneOR97401US CARVEDILOL 3.125 MG TABS CARVEDILOL one bid IRBESARTAN 150 MG TABS IRBESARTAN Take 1 tab by mouth once daily. IRBESARTAN 2830 Crescent AveEugeneOR97408US BeckyJHoward NP Costco Eugene* 2828 Chad DriveEugeneOR97401US B-12 1000 MCG CR-TABS B-12 2 QD, generic okay OTHER (N/A), OTHER (N/A), 1 QD, generic okay OTHER (N/A), 2830 Crescent AveEugeneOR97408US GordonPAnderson MD Costco Eugene* 2828 Chad DriveEugeneOR97401US CO Q 10 CAPS CO Q 10 1 QD, generic okay VITAMIN D3 1000 UNIT CAPS VITAMIN D3 3 tabs QD
Conditions or Problems
Problem Name Problem Code Onset Date Status Entry Date Provider Comment Standard Description Annotate
Allergic conjunctivitis 231854006 (SNOMED CT) 2015/07/21 Active 2015/07/21 Becky J Howard NP Atopic conjunctivitis
Osteoarthrosis, unspecified whether generalized or localized, involving ankle and foot M19.90 (ICD-10-CM) 2015/04/13 Active 2015/04/20 Drew D Pearson DPM Unspecified osteoarthritis, unspecified site
Other hammer toe (acquired) M20.40 (ICD-10-CM) 2015/04/13 Active 2015/04/20 Drew D Pearson DPM Other hammer toe(s) (acquired), unspecified foot
Hallux valgus (acquired) M20.10 (ICD-10-CM) 2015/04/13 Active 2015/04/20 Drew D Pearson DPM Hallux valgus (acquired), unspecified foot
Eye pain 41652007 (SNOMED CT) 2015/03/26 Active 2015/03/26 Becky J Howard NP Pain in eye
Eye pain, left 41652007 (SNOMED CT) 2015/03/26 Active 2015/03/26 Becky J Howard NP Pain in eye
Allergic rhinitis 61582004 (SNOMED CT) 2015/03/26 Active 2015/03/26 Becky J Howard NP Allergic rhinitis
Fatigue 84229001 (SNOMED CT) 2015/03/26 Active 2015/03/26 Becky J Howard NP Fatigue
Fasting hyperglycemia 390951007 (SNOMED CT) 2015/03/26 Active 2015/03/26 Becky J Howard NP Impaired fasting glycaemia
Toe pain 285365001 (SNOMED CT) 2015/03/26 Active 2015/03/26 Becky J Howard NP Pain in toe
PATHOLOGIC FRACTURE OF VERTEBRAE M48.56 (ICD-10-CM) 2014/09/03 Active 2014/09/03 Becky J Howard NP Collapsed vertebra, not elsewhere classified, lumbar region
SENSORINEURAL HEARING LOSS ASYMMETRICAL H90.5 (ICD-10-CM) 2014/07/16 Active 2014/07/16 Laura Hurn AuD Unspecified sensorineural hearing loss
PREVENTIVE HEALTH CARE 275926002 (SNOMED CT) 2014/06/05 Active 2014/06/05 Becky J Howard NP Screening - health check
VIRAL INFECTION 34014006 (SNOMED CT) 2014/01/18 Active 2014/01/18 Philip Chapa PA Viral disease
MASS, LUNG 309529002 (SNOMED CT) 2011/12/26 Active 2011/12/26 Gordon P Anderson MD Lung mass
PNEUMONIA 233604007 (SNOMED CT) 2011/12/16 Active 2011/12/16 Donna R Givens MD Pneumonia
COUGH 49727002 (SNOMED CT) 2011/12/16 Active 2011/12/16 Donna R Givens MD Cough
MIXED HEARING LOSS UNSPECIFIED H90.8 (ICD-10-CM) 2011/03/03 Active 2011/12/16 Brenda Leavitt NCMA Mixed conductive and sensorineural hearing loss, unspecified
MYOCLONUS 127324008 (SNOMED CT) 2011/02/15 Active 2011/12/16 Brenda Leavitt NCMA Myoclonic disorder
OTHER&UNSPECIFIED HYPERLIPIDEMIA 272.4 (ICD-9-CM) 2009/01/12 Active 2011/12/16 Brenda Leavitt NCMA Other and unspecified hyperlipidemia
COR ATHEROSLERO NATIVE COR ART I25.10 (ICD-10-CM) 2009/01/12 Active 2011/12/16 Brenda Leavitt NCMA Atherosclerotic heart disease of native coronary artery without angina pectoris
UNSPECIFIED ESSENTIAL HYPERTENSION 59621000 (SNOMED CT) 2009/01/12 Active 2011/12/16 Brenda Leavitt NCMA Essential hypertension
Allergies, Adverse Reactions, Alerts
Allergy Name Reaction Description Start Date Severity Status Provider
LIPITOR Lipitor (atorvastatin) [MYALGIA] 2009/03/02 Moderate Active Brenda Leavitt NCMA
ENALAPRIL MALEATE (ENALAPRIL MALEATE TABS) Enalapril (enalapril) [COUGH] 2008/12/04 Moderate Active Brenda Leavitt NCMA
Lipitor (atorvastatin) [MYALGIA] Enalapril (enalapril) [COUGH]
Social History
Concept Description Observation Name Observation Value Units Start Date
Alcohol intake ALCOHOL USE occ /day 2015/07/21
Former smoker SMOK STATUS former smoker 2015/07/21
ALCOHOL USE occ/day
Vital Signs
Date Name Value Unit Description
2015/07/21 BMI (Body Mass Index) 25.86 kg/m2 body mass index - 41909-3
2015/07/21 Body Temperature 99.2 [degF] temperature E&M
2015/07/21 BP Diastolic 80 mm[Hg] blood pressure, diastolic - 8462-4
2015/07/21 BP Systolic 132 mm[Hg] blood pressure, systolic - 8480-6
2015/07/21 Heart Rate 68 /min pulse rate E&M - 8867-4
2015/07/21 O2 % BldC Oximetry 99 % oxygen saturation, oximetry
2015/07/21 Weight Measured 179.60 [lb_av] weight E&M - 3141-9
2015/07/21 Weight Measured 81.64 kg weight in kilograms E&M
Results No information available.
Procedures No information available. 2830 Crescent AveEugeneOR97408US Crescent Medical Clinic Family Medicine 2830 Crescent AveEugeneOR97408US
Medications Administered No information available.
Immunizations No information available. 0 2830 Crescent AveEugeneOR97408US
Advance Directives There may be information available, but it has not been provided by the sender.
Assessments
Date Status Assessment
Atopic conjunctivitis (SNOMED CT: 231854006)
2015/07/21 Comment only He declines an allergy eye drop He uses systane drops.
Allergic rhinitis (SNOMED CT: 61582004)
2015/07/21 Comment only His updated medication list for this problem includes: Prednisone 20 Mg Tabs (Prednisone) ..... 2 tabs p.o. daily take total daily dose every morning w/ food He will try aloe vera with an occlusive dressing to soften the hypertrophic scar on right thigh.
Review of Systems
Review of Systems Description Start Date
Complains of persistent cough, cough up phlegm 2015/07/21
Others: left eye crusty 2015/07/21
Others: low energy 2015/03/26
Complains of excessive gas, loose bowels/diarrhea 2015/03/26
Complains of hoarseness; Others: raspy voice, some phlegm in the morning when clearing throat 2015/03/26
Complains of hearing loss, ringing/head noise, post nasal drainage, snoring; Denies ear pain, ear drainage, dizziness, nasal obstruction, sinusitis, altered sense of smell, hoarseness, sore throat, difficulty swallowing 2014/07/16
Denies hives, nasal congestion, itchy eyes, throat irritation, chronic cough, dry cough 2014/07/16
Denies coughing blood, pain with breathing, shortness of breath, wheezing, productive cough 2014/07/16
Denies heartburn, abdominal bloating / excessive gas 2014/07/16
Complains of fatigue; Denies night sweats, weight gain/loss 2014/07/16
Denies blurred vision, double vision 2014/07/16
Denies headache, numbness 2014/07/16
Denies skin growths/moles, 2014/07/16
Denies bleed easily, bruise easily, joint pain, lymph node swelling 2014/07/16
Denies depression, 2014/07/16
Family History No information available.
History of Past Illness No information available.
History of Present Illness
History of Present Illness Description Start Date
Antone is a 81 Years Old Male who presents with complaints of URI starting about _10 days__ ago. Symptoms include: runny nose, productive cough, sore throat. Overall, the symptoms are mild-moderate in severity. Denies the following: fever, SHOB, chest pain, abdominal pain. Pt has tried some OTC medicines which has provided some relief. His wife got something similar a few days before he did. Left eye has been crusty and voice hoarse. Has used a homeopathy remedy which was helpful in past but not this time. Mucinex taken for a while, no problem getting the phlegm out. Phlegm is white to off white. Right thigh has a scaly scar that is alongside a chainsaw injury 2-3 years ago, sustained while cutting a tree. It required 20 stitches but he wonders if there could be a foreign body in there. Responds to Aloe Vera.. 2015/07/21